Individual
LARRY O OTWELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
AUD CCCA
Contact information
Practice address
2518 S HIGHWAY 77 STE A, LYNN HAVEN, FL 32444-4730
(850) 769-2705
(850) 769-1097
Mailing address
2518 S HIGHWAY 77 STE A, LYNN HAVEN, FL 32444-4730
(850) 769-2705
(850) 769-1097
Taxonomy
Speciality
Code
Description
License number
State
231H00000X
Audiologist
Primary
AY370
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
600185800
—
FL
05
—
600237400
—
FL
01
—
AD782
MEDICARE GROUP
FL
01
—
K0176
MEDICARE OLD PTAN
FL
01
—
S1844
BCBS
FL
Enumeration date
09/07/2005
Last updated
04/03/2013
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